Medical opinion: Answers to abdominal pain could take many tests

Editor's note: Board-certified specialists from a panel of Yuma-area physicians provide to-the-point answers to questions submitted by Sun readers. The answers are only the opinions of the answering physicians and are not meant to be a substitute for medical consultation or physician care. Submit questions by e-mail to medicalopinion@yahoo.com or via regular mail at Yuma County Medical Society, P.O. Box 4476, Yuma 85366.

Q —  I have had near constant pain in my abdomen for over five years. I've been seen by a gastroenterologist, had several catscans, MRIs and ultrasounds performed, and have even been hospitalized and still my doctor is unable to give me a diagnoses. The pain increases substantially after I eat, and is so painful I compare it to childbirth. Doctors thought it could be my gallbladder, so it was removed. Pain subsided for awhile, but soon returned. Prednisone was prescribed and I took it for a year, then was slowly weaned off the drug. I need this resolved, what else can be done? Will I ever be pain free? Can you help?
 
A — Poorly characterized abdominal pain in a patient who has undergone extensive evaluation and prior surgery is a difficult problem. As a surgeon, my focus is on those processes which can be alleviated by an operation but with awareness of conditions which do not respond to surgery as well. While a CT scan and MRI are extremely useful tests, there are several intestinal conditions which may remain undetected.
 
One of my first questions in patients with chronic abdominal pain is "have you lost weight?” While this doesn’t help in directing the specific tests, I use it as a guide as to how aggressive a workup should be pursued. Another evaluation is the location of the pain, i.e. in the upper abdomen, central abdomen or lower abdomen. The latter typically involves colonic conditions which might be associated with changes in bowel habits, blood, etc. Surgical problems in the central and upper abdomen typically point to small intestine, stomach, gallbladder and pancreas which may be associated with vomiting in addition to pain. Abdominal pain that seems to tend towards the flank or back suggests retro-peritoneal structures (behind the intestines) and includes the kidneys, pancreas and first portion of the small intestine (the duodenum).
 
Occasionally heart, lung and back problems can be confused with abdominal complaints but this is usually not the case when the pain is of long standing duration. Gallbladder problems are a very frequent cause of abdominal complaints; gallbladder surgery is the most common operation performed in the United States. Most problems with the gallbladder, pancreas and liver can be evaluated by CT scan, MRI and ultrasound. Endoscopy is usually the best test for evaluating the stomach and colon for surgical disease. Adhesions (scar tissue), from prior surgery, injury or inflammation can sometimes cause partial blockage of the small intestine and thus pain after eating. Unless x-rays are taken which demonstrate obstruction as a result of the scar tissue, this can be a very difficult diagnosis to establish. Inadequate blood flow (intestinal ischemia) is another potential surgical problem associated with pain after eating but this is almost always associated with weight loss.
 
Without more specific complaints and/or direction in which to focus your evaluation, my approach to this problem is a step-wise manner with a history and physical examination plus basic laboratory studies including urinalysis. If none of this is helpful in determining the cause of pain, I would probably obtain a repeat CT scan of the abdomen and pelvis (depending on the interval since the last study). If this is unremarkable, the next step could be a trial of medication, usually something to decrease stomach acid and/or an anti-spasmodic or consideration of endoscopy which is typically carried out by a gastroenterologist. If none of the evaluations named above are helpful in demonstrating the cause of abdominal pain, consideration for surgery whether laparoscopic or conventional would only be undertaken if there is a strong suspicion of a specific surgical problem and usually preceded by a second opinion.


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Henri R. Carter, M.D., FACS, is the president of Arizona Medical Association.